单孔多通道3D腹腔镜肾癌手术的初步应用

目的:初步应用单孔多通道3D腹腔镜进行肾癌手术,探讨该手术是否安全可行,评估其优缺点和临床应用前景。方法:我中心从2014年1月起开展单孔多通道3D腹腔镜肾癌手术,至2015年1月共开展肾癌根治术6例,肾部分切除术2例。我们收集了8例患者的基本信息、住院期间各项临床指标及随访资料并进行分析。结果:8例患者手术均顺利完成,并未增加任何辅助切口。本组肾癌根治术和肾部分切除术的手术时间分别为(216.7±51.3)min、(217.5±31.8)min,术中出血分别为(336.7±443.9)ml、(100.0±70.7)ml。其中2例肾部分切除术热缺血时间为16min和24min。术中术后未输血,未出现并发症。患者于术后(2.4±0.5)天恢复胃肠功能,术后住院天数为(5.3±1.4)d。术后平均随访(25.5±3.7)个月,随访期间无肿瘤复发,切口无明显手术瘢痕,体表毁损程度小。结论:单孔多通道3D腹腔镜既具有单孔腹腔镜体表毁损程度小、术后患者疼痛轻、恢复快、切口及Trocar穿刺点相关并发症少等优点,又结合了3D腹腔镜图像立体感强、手术操作精确度高的优势,在一定程度上可以降低单孔腹腔镜缝合、打结等操作的难度,具有良好的临床应用前景。     

自制单孔多通道装置在泌尿外科单孔后腹腔镜手术中的应用(附167例报告)

目的探讨自制单孔多通道装置在泌尿外科单孔后腹腔镜手术中的应用。方法回顾分析了从2011年6月至2014年5月笔者进行单孔后腹腔镜单纯肾切除术57例、单孔后腹腔镜肾癌根治术35例、单孔后腹腔镜肾上腺切除术36例、单孔后腹腔镜肾囊肿去顶术39例,共167例患者的临床资料。均采用1个切口保护套和1个无粉外科手套组成一个单孔多通道操作装置,使用常规腹腔镜器械进行单孔后腹腔镜手术,术后手术伤口常规予皮内缝合。结果 167例患者均成功进行单孔后腹腔镜手术,无改行常规后腹腔镜手术或开放手术。单孔后腹腔镜单纯肾切除术手术时间(90.0±38.2)分钟,单孔后腹腔镜肾癌根治术手术时间(120.0±33.7)分钟,单孔后腹腔镜肾上腺切除术手术时间(45.0±16.3)分钟,单孔后腹腔镜肾囊肿去顶术手术时间(35.0±15.6)分钟。术中出血量20~200ml,术后无需要输血患者,无重大手术并发症。所有患者均对手术伤口愈合后残留的微小瘢痕感到满意。结论应用自制单孔多通道装置进行泌尿外科单孔后腹腔镜手术安全可行、费用低,减少手术创伤。联合伤口皮内缝合,达到了患者的美观要求,应用前景广阔,可作为有手术伤口美观要求的患者,特别是女性患者行相关手术的首选治疗方法。     

自制单孔多通道平台后腹腔镜技术在肾脏手术中的应用

目的探讨自制单孔多通道平台后腹腔镜技术在肾脏手术中应用的安全性和可行性。方法 2011年5月~2014年4月,采用自制单孔多通道平台,利用常规腹腔镜器械完成87例后腹腔镜肾脏手术,包括14例亲属活体供肾切取术,10例肾部分切除术,63例肾癌根治术。结果 14例亲属活体供肾切取术的手术时间、术中出血量、热缺血时间分别为(146.6±30.6)min(110~207 min),(66.7±90.6)ml(20~350 ml),(2.6±0.8)min(1.9~4 min);10例肾部分切除术和63例肾癌根治术的手术时间、术中出血量分别为(126.5±5.7)min(118~130 min)和(131.7±13.9)min(120~150 min),(30.0±20.4)ml(15~60 ml)和(36.9±9.7)ml(30~50 ml)。无中转行常规腹腔镜和开放手术,无输血,仅肾癌根治术组发生2例并发症(心房纤颤、切口愈合延迟)。结论采用自制单孔多通道平台的后腹腔镜肾脏手术技术可行,术式安全可靠,无须使用专用的特殊腹腔镜器械,降低了学习难度。     

自制套管行单孔后腹腔镜肾部分切除术

目的:探讨采用自制套管施行单孔后腹腔镜肾部分切除术的方法。方法:2009年5～11月采用单孔后腹腔镜施行肾部分切除术6例,其中男3例,女3例,平均年龄(54.3±12.6)岁。原发病为小肾癌4例,肾错构瘤2例;病灶位于右侧3例,左侧3例。手术采用气管内麻醉,经腹膜后入路。取患侧向上的全侧卧位,取肋下3～4 cm切口切开法进入腹膜后间隙,然后置入自制套管,通过此套管置入5 mm电子腹腔镜及常规操作器械进行肾手术。肾动脉阻断后行肾部分切除,创面缝扎止血。结果:6例均在单孔后腹腔镜下顺利完成手术。手术时间(140.0±44.3)min;肾热缺血时间(24.5±4.6)min;出血量(108.3±39.7)ml。无术中腹膜破裂、大出血、周围脏器损伤、术后继发出血、切口感染、肠梗阻等并发症。病理检查证实切缘均为阴性。术后(5.0±0.9)天出院。结论:应用自制套管对于选择性病例施行单孔后腹腔镜肾部分切除手术安全可行,切口创伤小,切口美观。     

腹腔镜肾部分切除术与根治性切除术治疗T2a期肾癌比较研究及三年随访总结

目的 比较在我院治疗的T2a期肾癌行腹腔镜肾部分切除术及腹腔镜肾癌根治性切除术的临床疗效。方法 回顾性分析2014年6月至2017年6月在伊犁州友谊医院泌尿外科经腹腔镜手术治疗的108例T_2a期肾癌的临床资料,其中行腹腔镜肾部分切除术患者56例,行腹腔镜肾癌根治术者52例。比较两种手术方式临床指标。结果 两组手术时间、术中出血量、术中输血率、术后住院期并发症发生率、术后住院时间对比差异均无统计学意义(P均>0.05);两组术后第3、6个月血肌酐相比较,差异均无统计学意义(P均>0.05),腹腔镜肾部分切除术组术后第12个月及36个月血肌酐显著低于腹腔镜肾癌根治术组,相比较差异均有统计学意义(P均<0.05)。术后随访3年,其中腹腔镜肾部分切除术组复发率为7.14%,根治术组复发率为9.62%,两组相比较差异无统计学意义(P>0.05)。结论 与腹腔镜肾癌根治术相比较,肾部分切除术在治疗T_2a期肾癌时不增加手术时间、术中出血量、住院时间及手术并发症,同时能够充分地保护肾功能,在情况允许时可作为优先选择的手术方式。     

单孔后腹腔镜下肾切除术九例报告

目的 探讨经腹膜后入路单孔腹腔镜下肾切除术的方法.方法 2009年4-10月行单孔后腹腔镜下肾切除术9例.男6例,女3例.年龄(50.9±14.1)岁.无功能积水肾5例、无功能萎缩肾1例、T_1肾癌3例.左侧5例、右侧4例.气管内插管麻醉,侧卧位,切开法进入腹膜后间隙,置入自制多通道套管.经套管置入30°标准腹腔镜及操作器械行肾切除手术.结果 9例均在单孔后腹腔镜下顺利完成手术.手术时间(121.1±42.3)min,出血量(95.6±60.9)ml.术中无腹膜破裂、大出血、周围脏器损伤,术后无继发出血、切口感染、肠梗阻等并发症.术后4～6 d出院.结论 应用自制多通道套管行单孔后腹腔镜下肾切除手术安全可行、创伤小、切口美观.     

机器人辅助腹腔镜肾动脉无阻断肾部分切除术与分支阻断肾部分切除术治疗cT1期肾癌的疗效比较

目的:比较肾动脉无阻断机器人辅助腹腔镜肾部分切除术与肾动脉分支阻断机器人辅助腹腔镜肾部分切除术治疗cT1期肾癌的临床疗效.方法:回顾性分析2014年5月-2018年9月我院同一手术团队完成的机器人辅助腹腔镜肾动脉无阻断和分支阻断肾部分切除术治疗58例cT1期肾癌患者的临床资料.肾动脉无阻断组31例,男19例,女12例,...     

单中心肾细胞癌患者临床病理特征、手术情况及10年变化趋势分析

目的:分析肾细胞癌患者临床病理特征、手术方式及近10年来变化趋势。方法:回顾性分析2008年1月～2017年12月我院1 498例行手术治疗的肾细胞癌患者的临床资料。结果:1 498例肾癌患者中,男1017例,女481例;平均年龄(55.9±11.73)岁;透明细胞癌1 278例,乳头状肾细胞癌84例,其他类型肾癌共计136例;病理检查发现有坏死117例,肉瘤样变36例,肉瘤样变肾癌患者中位生存时间为14个月,1年生存率63.0%;发现术前发生转移83例,发生静脉瘤栓47例;临床分期Ⅰ期1 257例,Ⅱ期及以上241例;行根治性肾切除术962例,行保留肾单位手术536例。结论:肾癌患者存在城乡分布差异,城镇患者比例高于农村患者;男性患者较女性可能有更高的病理级别。肉瘤样肾癌患者总生存时间及1年生存率明显低于肾癌患者整体水平;肾部分切除术能更好的保护肾功能,腹腔镜手术具有出血少、住院时间短的微创优势,机器人辅助腹腔镜手术与腹腔镜手术在术中出血、住院天数及术后肌酐方面未见明显差异,但手术时间长于腹腔镜手术。近10年来,肾癌患者年龄、性别、病理类型、病理分级各构成比未见明显变化,无症状患者比例逐年降低,行肾部分切除术及腹腔镜、机器人辅助腹腔镜微创手术比例逐年提高。     

后腹腔镜肾部分切除术治疗局限性肾癌的效果

目的分析后腹腔镜肾部分切除术治疗局限性肾癌的临床价值。方法选取2016-03-2018-11间本院收治的46例局限性肾癌患者并按照不同手术方式分为2组。给予对照组(20例)患者实施开放肾部分切除术,对研究组(26例)患者行后腹腔镜肾部分切除术。比较2组患者的手术时间、术中肾热缺血时间、术后并发症及手术前后肾功能变化等指标情况。结果研究组患者手术时间和术中肾热缺血时间长于对照组,但术中出血量、术后胃肠功能恢复时间、并发症发生率及住院时间均优于对照组,差异有统计学意义(P<0.05)。2组患者手术前后肌酐水平及患侧肾脏肾小球滤过率等差异均无统计学意义(P>0.05)。结论开放肾部分切除术与后腹腔镜肾部分切除术治疗局限性肾癌均有确切疗效,但后者手术创伤更小,术后恢复更快,安全性高。     

经脐单孔腹腔镜肾切除术2例报告

目的：初步探讨经脐单孔腹腔镜肾切除术的临床可行性和安全性。方法：2009年6～7月,对2例患者行经脐入路单孔腹腔镜肾切除术,1例右肾癌患者行单孔腹腔镜右肾根治性切除术,1例左侧积水性无功能肾患者行单孔腹腔镜单纯左肾切除术。患者取45。健侧卧位,作2．5cm绕脐“Z”形皮肤小切VI,Hasson法制备经腹腔入路单孔腹腔镜工作通道切口,置入单孔三通道腹腔镜操作通道。从单孔通道分别置人5mm腹腔镜和手术器械,按照标准的腹腔镜根治性肾切除术和单纯。肾切除术的手术操作步骤完成手术,切除标本均从脐部切口取出。结果：2例手术均顺利完成,手术时间分别为210min和90min,估计出血量分别为100ml和20ml,无中转开放及标准三孔腹腔镜手术,术中无并发症发生,短期随访无术后并发症发生。结论：小样本的临床研究结果初步显示了单孔腹腔镜。肾切除术良好的安全性和可行性。然而,该术式的临床治疗效果尚需大样本中远期随访和对照研究予以证实。     

单孔腹腔镜根治性肾切除术治疗肾细胞癌

目的探讨应用单孔腹腔镜手术(laparo endoscopic single-site surgery,LESS)行根治性肾脏切除术治疗肾脏肿瘤的临床安全性及可行性。方法 2010年11月至2011年4月,我们应用单孔4通道(Quadport)单孔腹腔镜根治性肾脏切除术技术治疗3例肾脏肿瘤,1例为右侧中央型4.2cm肾肿瘤,另两例分别为左侧肾下极7.4cm和肾中部4.5cm肾肿瘤。经脐部切口将Quadport置入腹腔,采用5mm头部可弯腹腔镜和标准腹腔镜直器械实施标准经腹腔途径腹腔镜根治性肾脏切除术。记录患者手术时间、估计术中出血量、术中并发症、留置引流管时间、术后住院时间和术后病理等临床资料,并对结果进行分析。结果本组3例手术均由LESS完成,无加辅助通道、无转标准腹腔镜手术或开放手术完成病例。仔细实施手术步骤,避免过度钝性分离组织造成术中出血是手术顺利进行的基础。采用Quadport减少了器械间的相互干扰。根治性肾脏切除术手术操作时间分别为215、230、170min,估计术中出血量分别为100、100、150ml。本组手术无术中严重并发症。术后留置引流时间分别为4、3、2d,术后住院时间分别为8、10、8d。本组术后无继发性出血和切口感染病例。病理结果示肾透明细胞癌2例,肾嫌色细胞癌1例,无淋巴结转移,病理分期分别为pT1bN0M02例,pT2aN0M01例。本组未见肿瘤侵及肾周围组织。结论 LESS根治性肾脏切除术治疗肾脏肿瘤是安全可行的,但需要更多的研究来进一步验证。     

肾癌肾部分切除术的临床价值及合适的手术切缘的探讨

目的：探讨肾癌肾部分切除术(保留肾单位手术)的临床价值及合适的手术切缘。方法：回顾性分析15例行肾部分切除术的肾癌患者临床资料．其中双侧异时性肾癌且一侧为多发肿瘤2例，单发肿瘤13例。肿瘤直径2～6cm．均为T1期(1997年TNM分期标准)。对15例肾癌患者行肾部分切除术．手术切缘位于肿瘤外1cm。另取肾癌根治性手术标本21例．于体外沿假包膜行肾肿瘤剜除术．并随机切取肿瘤边缘0．3cm、0．5cm及1cm处肾实质及肾蒂处淋巴脂肪组织行病理检查。结果：15冽患者随访12～72个月．平均41个月．未见并发症及残肾内肿瘤复发。21例标本于体外行肿瘤剜除后肉眼下均无肿瘤组织残留，送检组织均无肿瘤细胞浸润。结论：肾部分切除术能安全有效地治疗局限的早期肾癌患者．而手术切缘为肿瘤边缘1cm处较为合适。     

Surgical management of renal tumors: a historical perspective

The modern era of renal surgery began on August 2, 1869 when the first planned nephrectomy on a living human being was performed. Eighteen years later in 1887, the first partial nephrectomy to remove a renal tumor was performed. Both total and partial nephrectomy have become the hallmark surgical procedures used today to treat renal tumors, and their conception and evolution represent two of the most important advances in medicine and surgery. Surgery for kidney cancer continues to evolve. This article traces the history of surgical management for renal tumors.     

Laparoscopic partial nephrectomy

PURPOSE OF REVIEW: This review defines the current role, indications, contraindications, advances, complications, and outcomes of laparoscopic partial nephrectomy in the management of renal tumors. RECENT FINDINGS: Recent publications have widened the scope for the application of this technology. The new advances in the management of renal tumors and the tools for tumor excision, renal parenchymal reconstruction, hemostasis, renal vascular control to establish renal ischemia, and the ability to avoid positive surgical margins have made the procedure safe and feasible in the hands of an experienced laparoscopist. SUMMARY: The trend toward nephron-sparing surgery has become stronger even in the presence of normal contralateral functioning kidney. Data on oncologic efficacy are promising, and partial nephrectomy is becoming a standard therapy for renal tumors less than 4 cm in size in many centers. Laparoscopic partial nephrectomy has evolved significantly during the past 10 years in our experience as well as that of others. It cannot be considered as a standard yet, but it is being performed in rapidly increasing numbers with good surgical efficiency and oncologic efficacy parallel to that of open surgery.     

Open partial nephrectomy for tumor in a solitary kidney: experience with 400 cases

PURPOSE: We present a series of 400 patients with tumor in a solitary kidney who underwent open surgical partial nephrectomy performed by a single surgeon (ACN) with a primary focus on postoperative long-term kidney function. MATERIALS AND METHODS: A total of 400 patients with sporadic nonfamilial kidney tumors in a solitary kidney underwent open partial nephrectomy between 1980 and 2002. In 323 patients (81%) the contralateral kidney had been surgically removed, while the remaining 77 (19%) had a congenital solitary kidney. Renal insufficiency was present preoperatively in 184 patients (46%). Adverse risk factors for partial nephrectomy were present in a large percent of patients. Intraoperative and postoperative parameters were evaluated at a mean followup of 44 months. RESULTS: In the overall series 5 and 10-year cancer specific survival was 89% and 82%, respectively. Surgical complications occurred in 52 patients (13%), most commonly urinary leakage. Early postoperative renal function was achieved in 398 patients (99.5%). Only 2 patients required permanent dialysis postoperatively. Satisfactory long-term renal function was achieved in 382 patients (95.5%). A total of 18 patients had progressed to renal failure a mean of 3.6 years after surgery. Patient age, the amount of renal parenchyma resected, a congenitally absent or atrophic contralateral kidney and the time of contralateral nephrectomy were noted to be significantly associated with postoperative renal function. CONCLUSIONS: Open surgical partial nephrectomy can be safely performed in patients with tumor in a solitary kidney. Long-term cancer-free survival with the preservation of renal function can be reliably expected in most of these cases.     

Kidney cancer ablative therapy: Indications and patient selection

The increased application of radiographic imaging has paralleled a simultaneous increase in the detection of incidental and asymptomatic renal neoplasms. The reference standard for treating small renal tumors includes open and laparoscopic partial nephrectomy. The primary objectives of ablative renal procedures are to duplicate the excellent oncologic outcomes of partial nephrectomy while decreasing patient morbidity and shortening hospitalization and overall convalescence. Ablation, with cryotherapy or radiofrequency probes, offers the advantages of minimally invasive surgery, but with a significantly lower complication rate than laparoscopic partial nephrectomy. Ablation now represents a major change in surgical thinking as tumors are ablated and left in situ. This article reviews the status of the two ablative modalities currently available for clinical application, cryoablation and radiofrequency ablation.     

Open partial nephrectomy for the treatment of renal cell carcinoma

Open partial nephrectomy, or nephron-sparing surgery (NSS), is now considered the standard of care for the treatment of small renal tumors. The oncologic efficacy and safety of NSS for the treatment of stage-T1a renal tumors has been repeatedly demonstrated to be equivalent to radical nephrectomy. NSS initially was reserved for patients with solitary kidneys, impaired renal function, hereditary tumor syndromes, bilateral renal tumors, and those with significant comorbidities predisposing to future renal failure. The indications have expanded recently to allow elective partial nephrectomy in the setting of a normal contralateral kidney. Furthermore, recent data demonstrate that partial nephrectomy for larger tumors (T1b), which have been historically treated with radical nephrectomy, is a viable option when surgical margins can safely be achieved. In the era of minimally invasive techniques, laparoscopic NSS is technically feasible, yet long-term studies are still needed to assess oncologic efficacy. New NSS ablative technologies, such as cryoablation and radiofrequency ablation, are on the horizon. In this article, we discuss the role of open NSS and surgical technique in the contemporary management of renal tumors.     

Robotic partial nephrectomy for complex renal tumors: surgical technique

OBJECTIVES: Laparoscopic partial nephrectomy requires advanced training to accomplish tumor resection and renal reconstruction while minimizing warm ischemia times. Complex renal tumors add an additional challenge to a minimally invasive approach to nephron-sparing surgery. We describe our technique, illustrated with video, of robotic partial nephrectomy for complex renal tumors, including hilar, endophytic, and multiple tumors. METHODS: Robotic assistance was used to resect 14 tumors in eight patients (mean age: 50.3 yr; range: 30-68 yr). Three patients had hereditary kidney cancer. All patients had complex tumor features, including hilar tumors (n=5), endophytic tumors (n=4), and/or multiple tumors (n=3). RESULTS: Robotic partial nephrectomy procedures were performed successfully without complications. Hilar clamping was used with a mean warm ischemia time of 31 min (range: 24-45 min). Mean blood loss was 230 ml (range: 100-450 ml). Histopathology confirmed clear-cell renal cell carcinoma (n=3), hybrid oncocytic tumor (n=2), chromophobe renal cell carcinoma (n=2), and oncocytoma (n=1). All patients had negative surgical margins. Mean index tumor size was 3.6 cm (range: 2.6-6.4 cm). Mean hospital stay was 2.6 d. At 3-mo follow-up, no patients experienced a statistically significant change in serum creatinine or estimated glomerular filtration rate and there was no evidence of tumor recurrence. CONCLUSIONS: Robotic partial nephrectomy is safe and feasible for select patients with complex renal tumors, including hilar, endophytic, and multiple tumors. Robotic assistance may facilitate a minimally invasive, nephron-sparing approach for select patients with complex renal tumors who might otherwise require open surgery or total nephrectomy.     

Robot‐assisted laparoscopic partial nephrectomy versus laparoscopic partial nephrectomy: A propensity score‐matched comparative analysis of surgical outcomes and preserved renal parenchymal volume

Objectives

To compare surgical outcomes, including renal function and the preserved renal parenchymal volume, between robot‐assisted laparoscopic partial nephrectomy and laparoscopic partial nephrectomy using propensity score‐matched analyses.

Methods

In total, 253 patients, with a normal contralateral kidney, who underwent laparoscopic partial nephrectomy (n = 131) or robot‐assisted laparoscopic partial nephrectomy (n = 122) with renal arterial clamping between 2010 and 2015, were included. Patients’ background and tumor factors were adjusted by propensity score matching. Surgical outcomes, including postoperative renal function, complications, warm ischemia time and preserved renal parenchymal volume, evaluated by volumetric analysis, were compared between the surgical procedures.

Results

After matching, 64 patients were assigned to each group. The mean age was 56–57 years, and the mean tumor size was 22 mm. Approximately 50% of patients had low complexity tumors (RENAL nephrometry score 4–7). The incidence rate of acute kidney failure was significantly lower in the robot‐assisted laparoscopic partial nephrectomy (11%) than laparoscopic partial nephrectomy (23%) group (P = 0.049), and warm ischemia time shorter in the robot‐assisted laparoscopic partial nephrectomy (17 min) than laparoscopic partial nephrectomy (25 min) group (P < 0.0001). The preservation rate of renal function, measured by the estimated glomerular filtration rate, at 6 months post‐surgery was 96% for robot‐assisted laparoscopic partial nephrectomy and 90% for laparoscopic partial nephrectomy (P < 0.0001). The preserved renal parenchymal volume was higher for robot‐assisted laparoscopic partial nephrectomy (89%) than laparoscopic partial nephrectomy (77%; P < 0.0001). The rate of perioperative complications, surgical margin status and length of hospital stay were equivalent for both techniques.

Conclusions

Robot‐assisted laparoscopic partial nephrectomy allows to achieve better preservation of renal function and parenchymal volume than laparoscopic partial nephrectomy.     

Cryoablation and radiofrequency for kidney tumor

The detection of incidental and asymptomatic renal cortical neoplasms has concomitantly increased with radiographic imaging use. The gold standard for treating small renal tumors includes open and laparoscopic partial nephrectomy. Ablative renal procedures intend to duplicate the excellent oncologic outcomes of partial nephrectomy, while decreasing complications and shortening hospitalization time and convalescence. Only short and medium-term data are available, but ablation with cryotherapy or radiofrequency probes may achieve these goals. Ablation also offers the advantages of a minimally invasive surgical approach, with a significantly lower complication rate than partial nephrectomy. Ablated lesions are typically left in situ. Leaving potentially malignant tissues in place, albeit in a nonviable condition, certainly represents a major change in surgical thinking processes. This article reviews the status of cryoablation and radiofrequency ablation, the two ablative modalities currently available for clinical application.